Best Evidence Topic: Avoidance and Treatment of a Bronchial Stump Insufficiency following Major Lung Surgery

Objectives: Almost a century after the first successful pneumonectomy postoperative insufficiency of the bronchus stump remains one of the most feared complications in thoracic surgery. This complication is not only associated with high mortality and morbidity, but also the treatment itself is challenging for the surgeon.

Methods: A best evidence topic in thoracic surgery was written according to a structured protocol. The literature research was executed in Medline and the Cochrane Database on July 30, 2016. In addition, a cross screening of references of all potential articles was performed. All studies published since 1999 in English and German language were considered relevant.

Results: Our systematic literature research revealed 19 studies with a total of over 3,885 patients after exclusion of all non-relevant publications. There was a high heterogeneity among the publications in relation to the tissue used to augment the bronchial stump and most of them didn't apply any kind of randomization. The decisions were made by the surgeon and in most cases a coverage of the bronchus stump was only done in elderly patients with increased risk factors. Nevertheless, the bronchial stump seems to be covered more often after pneumonectomy particularly on the right side. There was no significant advantage of bronchus stump reinforcement in most publications owing the above mentioned reasons. However, a bronchus stump insufficiency occurred significant more frequent after hand-sutured stump closure (3.5 vs. 12.5%; p < 0.005) and after right pneumonectomy (1 vs. 8%; p < 0.005). If insufficiency has already happened the studies reported mortality rates up to 71%.

Conclusion: For that reason it is necessary to know the common underlying risk factors of a bronchial stump insufficiency to avoid this complication. A coverage of the bronchus stump with well vascularized tissue should be performed, especially after right sided pneumonectomy. However, if an insufficiency of the bronchus stump has already occurred, rapid diagnosis followed by emergency rethoracotomy is mandatory.

Die Autoren geben an, dass kein Interessenkonflikt besteht.